Clinical Review

Cutting the medicolegal risk of shoulder dystocia

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What’s the best way to reduce legal risks? A physician expert and clinical riskmanagement team developed practice recommendations based on actual cases.


 

References

Clip-and-save shoulder dystocia documentation form
Practice recommendations

Among the intrapartum events that constitute bona fide emergencies, shoulder dystocia stands out. This obstetric emergency is the focus of an increasing number of medical liability cases. Most lawsuits involving shoulder dystocia allege negligence as the cause of the brachial plexus injury, fractured clavicle or humerus, or other injury. The defendant physicians named in these suits are often accused of inappropriately managing the prenatal or intrapartum course or the dystocia itself—or of inadequately documenting the steps taken to resolve the emergency.

To glean insights into the litigation process as it involves shoulder dystocia, we retrospectively reviewed all cases closed by the Boston-based ProMutual Group, a major liability insurance carrier, over a 7-year period. We wanted to learn more about the plaintiffs themselves, as well as the clinical and medicolegal factors that led to jury awards or indemnity payments. We also wanted data that could serve as the foundation for guidelines on how to proceed in the event of shoulder dystocia, as well as a documentation tool.

CASE 1 Discrepancies, delayed assistance

This shoulder dystocia case from an insurer’s closed claim file illustrates a problem often linked to litigation. Minor changes were made to conceal the identities of the involved parties.

Nurse and physician document different times

A 31-year-old woman in her 10th week of pregnancy had one prior uncomplicated vaginal delivery of a 9 lb 7 oz infant. Her prenatal course proceeds unremarkably, with a normal glucose tolerance test and total weight gain of 36 lb. At 41 weeks and 2 days, the estimated fetal weight is documented as 4,120 g. Labor is induced with oxytocin. Because of maternal fatigue, vacuum delivery is attempted.

Notes of the physician and the nurse differ regarding the time of the first of 3 vacuum applications.

After delivery of the head, shoulder dystocia is encountered. In a note handwritten immediately after delivery, the physician states that the head was “reconstituted as right occiput anterior with the left shoulder anterior.”

In a note dictated later, however, the same physician states the right shoulder was anterior.

Help is summoned and arrives 20 minutes after the dystocia is first encountered. The time that help was summoned is in question since there is an 18-minute discrepancy between the times the physician and the nurse note that assistance was called.

Despite the use of suprapubic pressure and maneuvers including McRoberts and Wood’s corkscrew, shoulder dystocia persists for 24 minutes. Apgars of the 11 lb 3 oz infant are 0, 1, and 3. The child is resuscitated but dies within 2 days of birth.

Outcome

Settled with a 7-figure indemnity payment.

What the defense experts said

The key issues involve documentation and summoning assistance. Discrepancies in documentation almost always cast doubt upon the credibility of a defendant. Ideally, there should be no discrepancies between nurse and physician notes and, certainly, no discrepancies between 2 notes on the same case by the same physician. If, in this case, the physician realized after writing the first note that the anterior shoulder had been incorrectly identified, a correction should have been written as a separate note.

Use of the shoulder dystocia documentation tool (see) helps create a chronology of events, which may prove vital to a successful defense.

The call for help might not have been delayed if the labor and delivery unit had had a shoulder dystocia protocol including “drills” for all team members. Help should be called as soon as a shoulder dystocia is encountered so that, when needed, it is available. Under no circumstances should it take 20 minutes for assistance to arrive.

Brachial plexus injury not always caused by shoulder dystocia

Between 21% and 42% of shoulder dystocias involve an injury1—usually brachial plexus injury. Plaintiff attorneys have manipulated this fact to attribute many cases of neonatal brachial plexus injury to mismanagement of shoulder dystocia by the obstetrician.

They fault the physician for failing to estimate fetal weight, perform a timely cesarean, use appropriate maneuvers correctly, or have a pediatrician present. They criticize nothing more resoundingly than use of “inappropriate” or “excessive” lateral traction to the fetal head.2

Nontraction injuries. The reality can be strikingly different, however. Some cases of brachial plexus injury involve no traction at all.

  • Brachial plexus injuries have been reported in infants who had precipitate vaginal deliveries without any physical intervention by the obstetrician.2
  • These injuries also have occurred in infants delivered via cesarean section.1,3,4
  • In some cases, brachial plexus injuries have affected the posterior arm of neonates whose anterior arm was involved in shoulder dystocia.1,2,5-7

A retrospective study4 found that, of 39 cases of brachial plexus injury, only 17 were associated with shoulder dystocia. Similar findings have emerged from other studies.2,3,8

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